Healthcare Provider Details

I. General information

NPI: 1235457581
Provider Name (Legal Business Name): JENNIFER LYNN HENDRICKS PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JENNIFER LYNN HUMENIUK PHARMD

II. Dates (important events)

Enumeration Date: 05/12/2010
Last Update Date: 01/30/2020
Certification Date: 01/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9812 MERCY RD APT 3
SAN DIEGO CA
92129-5041
US

IV. Provider business mailing address

10181 SCRIPPS GATEWAY CT
SAN DIEGO CA
92131-5152
US

V. Phone/Fax

Practice location:
  • Phone: 513-504-8796
  • Fax:
Mailing address:
  • Phone: 513-504-8796
  • Fax: 844-713-1304

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number72718
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number10131
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number0332773
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: